Billing rules and the claims workflow

Billing rules determine how completed trips are priced. Claims turn a completed, billable trip into a submittable form, whether that's a downloadable CMS-1500 or an electronic submission through a connected clearinghouse.

Billing rules

Billing rules determine how completed trips are priced and how billing details are represented on claims. A rule may use combinations of payer, service type, mobility level, trip type, service area, mileage, and modifiers.

Configure a billing rule

1. Open Settings or the billing rules area available to your role.
2. Create a rule or edit an existing rule.
3. Select the Service Type from the dropdown. The control uses the same selection pattern as the trip Mobility Level field.
4. Configure the applicable mobility level, trip type, base or mileage rate, and payer.
5. Select the service area: Rural or In Town.
6. Add the required billing modifier when the payer or service area requires one.
7. Save the rule and test it against a representative trip before using it for production billing.

Dispatchers must select the service area when creating a trip because Rural and In Town trips may use different rates. The resulting modifier is carried into claim billing based on the trip's service area and the matching billing rule. Avoid overlapping rules with the same payer, service type, mobility level, trip type, and service area — if more than one rule could apply, review priority and effective dates with the billing administrator.

Claims and billing

Open Claims to review billable trips, create claims, validate claim details, download forms, and submit claims through an electronic billing connection when configured.

Generate a claim from a trip

1. Confirm that the trip is complete and that required completion evidence is present.
2. Review patient, payer, service type, mobility level, service area, mileage, and modifier details.
3. Generate the claim from the trip.
4. Review the diagnosis code. The default diagnosis code is R68.89, but billing staff should confirm that the code is appropriate for the claim and organizational policy.
5. Review claim totals, modifiers, and payer-specific requirements.
6. Save or submit the claim according to its validation status.

The claims list is paginated — use search and filters to work a manageable set of claims by status, payer, date, or other available criteria.

Trip sheet from a claim

Claims include a linked trip-sheet download option. This download is intentionally the standard two-page claim document. The separate trip interface provides the expanded trip sheet with the third location-verification page for audit review.

CMS-1500 download

When a third-party billing provider requires a paper or file-based form, use the claim's CMS-1500 download option when available. Review the generated form before sending it to the billing provider, especially patient identifiers, payer information, diagnosis, dates, units, amounts, and modifiers.

Electronic claim submission

Electronic submission requires an organization-approved EDI connection and payer configuration. Before submitting:

• confirm the billing provider or clearinghouse connection is configured;
• confirm payer identifiers and enrollment requirements;
• validate provider, patient, service, diagnosis, and claim amounts;
• review claim errors and warnings;
• submit only after the claim is ready.

After submission, retain the platform response and monitor claim status. A submission request is not the same as payer acceptance or payment. Claims may move through draft, ready, submitted, paid, denied, or partially paid states depending on the response and follow-up activity.